Query Physicians to Improve Documentation and Dx Coding

Failing to thoroughly document signs and symptoms, assessments, and treatments of chronic diseases creates a ripple effect of misfortune. First, all relevant codes are not captured; this leads to improper payment (not to mention, an injustice to the patient). The next thing you know, the claim fails a Risk Adjustment Data Validation (RADV) or Office of Inspector General (OIG) audit based on insufficient documentation. The final blow is a funding take-back. Physicians know this, but many of them do not know how to document sufficiently to support the eight to 10 (or more) diagnoses they might list in the assessment. This is where the healthcare business professional’s expertise comes into play.

You can achieve necessary documentation improvements in a physician practice through:

Education – Physician education has been a standard in the quest for improved documentation. The drawback of providing education, only, is that it takes extensive repetition to achieve small improvements.

Physician Queries – Queries are often used in hospitals to achieve compliant documentation and appropriate diagnostic related groups (DRGs). The Center for Medicare & Medicaid Services (CMS) has adopted query guidance for hospital needs, but there is nothing in the guidance to indicate queries are only for hospitals. So why not use them in the physician office?

Follow Up, Repetition, and Persistence – This may be the most important part of the equation.

For now, let’s focus on the physician query piece of the equation. For convenience, I will use the term “addendum” in place of all terms modifying the record after the fact, whether that be a “late entry,” “amendment,” or “correction.”

Should the Medical Record Be Addended?

It’s ethical and proper to addend a visit note when it’s done to better document the management for existing diagnoses related to that visit, or for new diagnoses resulting from tests ordered during that encounter. Guidance from CMS and other clinical documentation improvement (CDI) organizations acknowledges the need for addendums, and agrees on their content. All recommend that organizations develop an internal addendum policy.

Published Q&A sessions from the early CMS Risk Adjustment Regional Training sessions include several references containing addendum guidance. For example:

Only the attending physician can correct the medical record. The amendment should be based on an observation of the patient on the date of service and be signed by the observing physician (e.g., a follow-up note based on a diagnostic test ordered and test results received subsequent to the patient visit).

“Attending physician” can be interpreted as whoever saw the patient for that visit and documented the note—whether that be a physician, a physician assistant, or nurse practitioner—as long as they are an acceptable provider type.

Guidance for Compliant Queries

Noridian instruction for Jurisdiction E – Medicare Part B, last updated on July 16, 2015, which revised an article that first appeared in Medicare Part B News (Issue 236, April 17, 2007), explains:

Noridian – Documentation Guidelines for Amended Records

Amended Medical Records

Late entries, addendums, or corrections to a medical record are legitimate occurrences in documentation of clinical services. A late entry, an addendum or a correction to the medical record, bears the current date of that entry and is signed by the person making the addition or change.

Late Entry: A late entry supplies additional information that was omitted from the original entry. The late entry bears the current date, is added as soon as possible, is written only if the person documenting has total recall of the omitted information and signs the late entry.

Example: A late entry following treatment of multiple trauma might add: “The left foot was noted to be abraded laterally. John Doe MD 06/15/09”

Addendum: An addendum is used to provide information that was not available at the time of the original entry. The addendum should also be timely and bear the current date and reason for the addition or clarification of information being added to the medical record and be signed by the person making the addendum.

Correction: When making a correction to the medical record, never write over, or otherwise obliterate the passage when an entry to a medical record is made in error. Draw a single line through the erroneous information, keeping the original entry legible. Sign or initial and date the deletion, stating the reason for correction above or in the margin. Document the correct information on the next line or space with the current date and time, making reference back to the original entry.

Correction of electronic records should follow the same principles of tracking both the original entry and the correction with the current date, time, reason for the change and initials of person making the correction. When a hard copy is generated from an electronic record, both records must show the correction. Any corrected record submitted must make clear the specific change made, the date of the change, and the identity of the person making that entry.

CMS includes addendum guidelines in the Medicare Program Integrity Manual, Chapter 3. These guidelines are directed at the MAC, ZPIC, PSC, CERT, and RACs, covering what is acceptable as they audit documentation and coding:

Transmittal 442, Change Request 8105, effective Jan. 1, 2013

Policy: Providers are encouraged to enter all relevant documents and entries into the medical record at the time they are rendering the service. Occasionally, upon review a provider may discover that certain entries, related actions that were actually performed at the time of service but not properly documented, need to be amended, corrected, or entered after rendering the service.

The manual goes on to explain:

Recordkeeping Principles: Regardless of whether a documentation submission originates from a paper record or an electronic health record, documents…containing amendments, corrections or addenda must: Clearly and permanently identify any amendment, correction or delayed entry as such. Clearly indicate the date and author of any amendment, correction, or delayed entry. Not delete but instead clearly identify all original content.

Electronic record vendors perform addendums in various ways. For example, in EPIC, the addended record is seen first. It’s identified as being amended, and is electronically signed and dated by the person making the addendum. There is a link to all previous versions of the note, which you can view. The important thing is that previous versions can be identified and easily accessed.

Describes or is associated with clinical indicators without a definitive relationship to an underlying diagnosis

Includes clinical indicators, diagnostic evaluation, and/or treatment not related to a specific condition or procedure

Provides a diagnosis without underlying clinical validation

Is unclear for present on admission indicator assignment

The main things to remember when querying are:

Not to lead

Not to question the clinical judgment of the provider

Not to indicate the financial impact

Include clinical indicators

Query Formats

There are three accepted standard query formats:

Open-ended: For use when there are clinical indicators in the note for a new diagnosis, but there is no diagnosis noted.

Multiple Choice: Choices should include clinically significant and reasonable options per the health record. A new diagnosis can be one of the choices because clinical indicators are referenced. It’s recommended that multiple-choice queries include options such as “clinically undetermined” and “not clinically significant.”

Yes/No: For example, when the documentation indicates the patient has diabetes mellitus and a common complication of diabetes, but has not indicated a link between the two. A new diagnosis may not be derived from a “yes/no” query.

What and How Much to Query

As an example, for Medicare Advantage and the Marketplace, I query only for Hierarchical Condition Categories (HCC) clarification, not for RxHCC. Although RxHCC is important, it’s more important to focus on effort where there is the highest risk for funding take-back, and where the best return is. According to “Managing an Effective Query Process” (AHIMA, August 2011):

Queries are not necessary for every discrepancy or unaddressed issue in physician documentation. Healthcare entities should develop policies and procedures that clarify which clinical conditions and documentation situations warrant a request for physician clarification. Insignificant or irrelevant findings may not warrant a query regarding the assignment of an additional diagnosis code, for example. Entities must balance the value of collecting marginal data against the administrative burden of obtaining additional documentation.

It is up to your organization to decide where the query value lies, and whether and how to prioritize the query process.

Timeline for Queries

Medicare doesn’t specify a timeline for queries. I use published guidance from a 2004 Risk Adjustment Regional Training for Medicare Advantage Organizations Questions & Answers session:

Only the attending physician can correct the medical record. The correction should be within 30 days of the initial documentation, and substantial reasoning must be provided for the change. The amendment should be based on an observation of the patient on the date of service and signed by the observing physician (e.g., a follow-up note based on a diagnostic test ordered and test results received subsequent to the patient visit).

Bottom Line for Physician Offices

The query should be related to information or action taken during the specific date of service being queried. For example:

Results of a lab, imaging, etc., ordered as part of the face-to-face patient visit not brought into the note

A diagnosis on the active problem list for the visit without documentation indicating it was addressed/assessed as part of the visit. It’s reasonable to assume these were assessed, but not documented, when the physician has them in the current visit note problem list.

Clinical indicators documented in the visit note without an accompanying diagnosis

A diagnosis coded/billed without indicating it was addressed/assessed during the visit

Contradictory information in the visit note

Query to add both the appropriate diagnoses and to remove resolved diagnoses inappropriately coded. Sometimes, the outcome of the query response isn’t expected (e.g., a diagnosis that
appeared to exist has resolved, or a diagnosis that seems to “come from nowhere” is an established diagnosis that has never been documented).

Whether the query becomes part of the health record or is saved in an administrative file is up to your organization. This also depends on whether the physician is addending the visit note, or is only attaching his response to the query.

Sample Query Templates

Diabetes Mellitus and Complication Not Tied Together

“This patient has diabetes mellitus and hyperlipidemia. Please addend the visit note dated xx/xx/xx to document the relationship, if any, between the diabetes and the hyperlipidemia. Thank you.”

Contradictory Visit Note

“There is contradictory information in the visit note. Documentation in the respiratory section of the note states the patient does not have any respiratory diagnoses, yet the Assessment states the patient does have COPD. If the patient does have COPD, please addend the visit note. If the patient does not have COPD, please remove the diagnosis. Thank you.”

“There is contradictory information in the visit note. Documentation in the Social History section of the note indicates the patient has never smoked, yet the Assessment states the patient has chronic bronchitis due to smoking. Please addend the visit note to resolve the contradiction. Thank you.”

Abnormal Findings

Often there are clinical indicators within the note itself.

“Foot exam indicates abnormal findings of reduced sensation found on monofilament test and reduced vibration sense. Is there a resulting diagnosis for these clinical findings? If yes, please addend the visit note with any resulting diagnosis. Thank you.”

Test Results Not Addended to Visit Note

“Ultrasound ordered from office visit xx/xx/xx indicates atherosclerosis of extremity. If you agree with this diagnosis, please addend the visit note dated xx/xx/xx with the test findings and resulting diagnosis. Thank you.”

Cancer

Cancer that has been excised is always a problem area, especially with primary care providers.

“On xx/xx/xx active cancer was listed in the Assessment. If the patient is on active treatment such as adjunct treatment, please addend the visit with the status and management. If the patient has completed treatment and is no longer on active or adjunct treatment, please addend the visit with the history of diagnosis. Thank you.”

Make It Work

How you implement your query process depends on whether the physicians are affiliates or are a part of the organization. Affiliate physicians often have less “skin in the game” and are less willing to work on their documentation, so pre-bill documentation reviews may be warranted.

How successful your query process is depends on the engagement of the physicians and their familiarity with the query process. Over-achievers will want to improve and do everything right, while others will want you to go away so they can keep doing the minimum.

CMS recommends that each facility develop an escalation policy for unanswered queries, and address staff concerns regarding queries. The escalation process may include referral to a physician advisor, the chief medical officer, or other administrative personnel.

To deliver the query, use a secure method of messaging and responding that is compliant with the use of personal health information. When the auditor and the physician both have continued access to an electronic health record (EHR), staff messaging inside the EHR is an option. The auditor needs the ability to access any record addendums that are completed.

Sometimes, it takes more than one query attempt to get documentation addended. This occurs more often in the beginning, before the physicians really understand what an auditor is looking for. As physicians get used to what you are looking for in the documentation, they will begin to document more thoroughly.

Diane Barton, CPC, CDEO, CPMA, CRC, CCS-P, is an AAPC Fellow who has worked for Medicare Advantage for 11 years, and has used outpatient physician queries for documentation improvement since 2007. She is the manager of Risk Adjustment & Quality Assurance for a Medicare Advantage in Houston, Texas, and is a member of the Houston, Texas, local chapter.

Diane Barton, CPC, CDEO, CPMA, CRC, CCS-P, is an AAPC Fellow who has worked for Medicare Advantage for 11 years, and has used outpatient physician queries for documentation improvement since 2007. She is the manager of Risk Adjustment & Quality Assurance for a Medicare Advantage in Houston, Texas, and is a member of the Houston, Texas, local chapter.

Diane Barton, CPC, CDEO, CPMA, CRC, CCS-P, is an AAPC Fellow who has worked for Medicare Advantage for 11 years, and has used outpatient physician queries for documentation improvement since 2007. She is the manager of Risk Adjustment & Quality Assurance for a Medicare Advantage in Houston, Texas, and is a member of the Houston, Texas, local chapter.

One Response to “Query Physicians to Improve Documentation and Dx Coding”

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